My First Combined Epidural / Spinal Neuraxial Anesthesia

[DrAmir0078]

Dear Fellows
I hope you are doing well, so in my post, I will discuss a detailed approach of combined Epidural / Spinal Neuraxial Anesthesia done by me, assisted by my senior resident and with the presence of the Attending.

Short History of the case:
Middle age young male, 80 Kg, presented with moderate subcutaneous hematoma around his knee and upper thigh due to motor vehicle crash accident, history of smoking, nill Past Medical or Surgical specific history. The Ortho surgeon explained he wants to do "evacuating of the hematoma", and his expected operation time is around 1 hour per surgeon; then and we offered combined Epidural / Spinal Anesthesia!

Note: This is my first month of residency (although it is a Urology rotation, but the OR floor celebrates Maxillofacial, Thoracic, Neuro and vascular surgeries every day)

Procedure:
* Surgical Hand scrubs done
* Gloves in
* Trolley has a clean sterile gown, preparing 5 syringes :
1- Two of 20 mm Syringe, one we have used it to calculate the amount of local Anesthetics:
Calculation:
Lidocaine 2% with epinephrine (by a dose of 5 mg/kg - normal dosage 5-7 mg/kg if with epinephrine vs 3-4 mg/kg if without) = that means 5 X 80 = 400 mg, since it is a maximum dose, we planned to give half the dose which is 200 mg = 10 ml (1ml of 2% = 20 mg)
Bupivacaine (isobaric) 0.5% = with the dose of 3 mg/kg (the minimum dose) = 240 mg = half of the dose = 120 = (each one ml = 5 mg) = 24 ml = we planned to give 10 ml
So 10 ml of Lido + Bupi = 20 ml in One Syringe
2- One 5 ml syringe for 2 ml only of 2% Lidocaine for infiltration
3- One 5 ml syringe for 1 ml only of 0.5% Bupivacaine
4- One 10 ml syringe of 10 ml Normal Saline

* 4X4 surgical pack (gauze) about 4 of them
* Epidural kit (opened on the trolley)

Preparation the site:

Patient was on Semi-setting position 90ْ degree, the lower half of the back was cleaned twice with povidone iodine, then let it almost air dry and wiping the central back with sterile 4 X 4.
Site of preference was L3/L4 by taking the imaginary line between both iliac crest. Infiltration of 2 ml of 2% Lido, started between the L3/L4 spinous process (Skin, subcutaneous tissue and fat, supraspinous, then at the both sides of the interspinous ligament), back to the subcutaneous to create a wheal like bump !

Then, inserting Tuohey needle, just 2 cm, then trocar out, then applying the Syringe for Air LOR technique, and it wasn't successful up to 5cm, because I faced the bone, (probably scoliosis like), then retracted 2cm and went more cephalad with lateral-medial Syringe-needle tip respectfully and just 6 cm, could get the loss, I didn't inject more than 5 cm of air !

After that, a test dose of LA (The mix in the 20 ml syringe - 3 ml given) !
Vital Sign were normal - Pulse Rate PR was 110 bpm

2 minutes, no change to 20% of PR - kept within the same !

Then, by holding the needle in that direction (was a bit difficult, not to lose the place), I injected up to total of 15 ml of 20 ml containing the mix !

Then, inserting the spinal needle (with the trocar) and could get CSF and injecting after withdrawing the trocar, the only 1 ml of Bupivocaine, the trocar back in and then withdrawing both the needle and the trocar.

Then, the epidural catheter inserted up to 15 cm ''' (can't go beyond it), then we test the dropping of normal saline (we filled it prior) and to double confirm that we are in the space!

Tuohy needle was carefully taken out, coiled the catheter around the site, a gauze and tapes to fix, the catheter placed from his back up to his right shoulder where the flat-filter (heplock) attached.

Then patient was positioned supine, vital sign were carefully watched !

5 - 7 minutes later, patient was hardly moving his legs (motor function was disabled), beside the sensation !

The entire operation of 80 minutes, the patient was fully awake, no deterioration of his Vital signs !

After the operation, catheter was removed and the patient was sent to the ward, discharged well. (he didn't need the left 5 ml of the LA mix)


--------------------------- The End

Any concern vs note regarding the technique, dosages, or any ? I am asking to learn with you !

The other day (We had 2 hours operation with only 20 ml of Lidocaine = 400 mg) + the 1 ml of 0.5% Bupivacaine (That patient had fracture femur)


Thanks for your time to read me and teach me!


Peace,

Amir

---

Members don't see this ad.

 

[POW16]

Why the spinal catheter?

 

[DrAmir0078]

Why the spinal catheter?

I believe to aid for a denser block!

Do you think, only Epidural with such technique and our dosages are enough?

 

[dhb]

I believe to aid for a denser block!

Do you think, only Epidural with such technique and our dosages are enough?

It looks like you did a complicated anesthetic for a fairly simple surgery.
A single shot spinal would be the most reasonable way to do this case.

 

[DrAmir0078]

It looks like you did a complicated anesthetic for a fairly simple surgery.
A single shot spinal would be the most reasonable way to do this case.

It happened before, sometimes the spinal won't work for some reasons.
At the same time, the operation was at the end of the day shift in the OR.
Probably, I am justifying!
Otherwise, I hope as a "Procedure" written above was not missing a detail or it needs adjustment of the dosages, if any!

 

[caligas]

Amir,

You seem quite interesting.

I would be interested to hear about the training process in Iraq. Is anesthesia competitive? How long do you train? What is life like as an attending, good money? Lots of hot babes?

Please share.

 

[Psai]

If the spinal doesn't work, just throw in an lma

I would also like to hear about hot babes

 

[DrAmir0078]

Amir,

You seem quite interesting.

I would be interested to hear about the training process in Iraq. Is anesthesia competitive? How long do you train? What is life like as an attending, good money?

Please share.

Okey,
Training Process:
Anesthesia is competitive, to get into the residency, you have to :
1- Acquired MD like Degree which in Iraq is MBChB
2- Two years of rotation - internship Or if you completed it, you are either a SHO in Anesthesia / General Practitioner in Anesthesia , then you have to pass a competitive test to get into the residency (lots of paperwork within)
3- Training course of the program is 4 years - In Iraq we have two residency programs offered by the Iraqi Ministry of higher education called the Iraqi Board (it is run by the department of Iraqi Board of Medical Specialities ) Or the Arabic Board (Arab Countries has an educational council) and in Iraq is run by the Ministry of Health as an affiliation {it is paid training like to pay 300$ a year beside each exam} .
You have these 4 years, has exams
PGY1 exam the most difficult written exam one day as MCQs - pass is 70 in Iraqi Board and 60 in Arabic Board and next few days will have short assays exam, if you pass MCQs will get your short assays graded otherwise failed! This exam held every October at the end of the PGY1 and repeated every 6 months.
There is Assessment exam at the end of the PGY3 or CA2 which is OSCE based! Also has repeat!
Finally you have the Board exam by the end of PGY4, MCQs, written and OSCEs. Also has repeat up to 4 times !
Then you can be a Board certified Anesthesiologist.
You can take Arabic Board while you are Iraqi Board one and vice versa.
Opportunities are available like getting different degrees like FRCA or European Diploma, but not the US one!
4- The life as an Attending is depends on where you are, I mean the city !
Salary wise : You are probably will get by that time as Attending about 2000 + US$/ month and it has bonuses every year, but this if you are working in government hospital(but also the government hospitals most of the time has private floor and this bring good money between depend on how much private, type of operation, like some Attending can easily get 3000 US$), and most of the Attendings like to also work in Private Hospitals (you will get 10 - 15% of the cost of the operation), some attendings could earn lots of money, but let us to say daily 3-5 operations and that means at least 300-500 US$ and you count (if you are a good Anesthesiologist) 500 X 5 days = 2500 X 4 = you ended up 10, 000 US$ (not bad) but in some very classy hospitals, you will ended up getting double of that (sometimes, but you have to be a machine) !
Don't forget, if you have sub-speciality like in Pain management (you are the king), you will probably get from your own clinic at least 10 patients a day and with your Private Hospitals - Some Painists (lol- sounds a good term), will get like 20 000 US$ a month as a total (Salary, GA, Clinic, Pain , , , etc) and that counts XXXXXX US$ a year (tax free - although the Salary has some taxes but no filing, some regulations count), well this for the top rated ones !

If the spinal doesn't work, just throw in an lma

@Psai LMA is interesting, but he is a smoker, that means a challenging management, isn't it? but how about the doses of LA?


Respect !

 

[WholeLottaGame7]

It was a little hard to tell, but based on your description of the procedure and the doses of local anesthetic, it sounds like you placed an epidural catheter, not a spinal catheter. It is an important distinction to make, as a normal epidural dose of LA will result in a number of complications if given in the intrathecal space, such as hypotension and respiratory depression (a high spinal).

It sounds like you placed the Tuohy, administered the loading dose of LA, then placed the epidural catheter. The fluid you drew back at that point was likely not CSF but the LA you had previously administered. To perform a combined spinal/epidural, you would (hopefully) have to place a spinal needle through the Tuohy needle to enter the CSF. You could poke the Tuohy into the CSF, but that would result in a very high probability of a post-dural puncture headache due to the size of the hole.

Agree with others that placing an epidural catheter for a 1 hour surgery may be a bit unnecessary, unless pain control was going to be an issue postoperatively. Since you removed the catheter at the end of the surgery, that doesn't seem to be the case. A single shot spinal would be faster (for you and the patient), easier, and result in a more reliable block than an epidural for this case.

 

[jope]

For a healthy patient that only smokes with no clear history of GERD. It's probably local culture, but most academic centers in Canada would probably just do a GA with an LMA and titrate some opioids. It doesn't sound like there will be lots of postop pain. In addition, just being a smoker is not an indication for a neuraxial technique either.

 

[DrAmir0078]

It was a little hard to tell, but based on your description of the procedure and the doses of local anesthetic, it sounds like you placed an epidural catheter, not a spinal catheter. It is an important distinction to make, as a normal epidural dose of LA will result in a number of complications if given in the intrathecal space, such as hypotension and respiratory depression (a high spinal).

Yes, it is true, it was an epidural !

It sounds like you placed the Tuohy, administered the loading dose of LA, then placed the epidural catheter. The fluid you drew back at that point was likely not CSF but the LA you had previously administered. To perform a combined spinal/epidural, you would (hopefully) have to place a spinal needle through the Tuohy needle to enter the CSF. You could poke the Tuohy into the CSF, but that would result in a very high probability of a post-dural puncture headache due to the size of the hole.

Yes, after I loaded the epidural space with LA, I inserted through the Tuohy needle the spinal needle (very small size) and could go further and felt poking the dura and could get the CSF coming out slowly, then I injected the 1ml of 0.5% Bupivacaine, then after that I withdraw the spinal needle with the trocar out, and kept the tuohy in, then introduced the epidural catheter for about 15 cm, we checked the dropping of NS ... etc

The question is "You prefer to poke the dura with the spinal needle first 'placed inside the tuohy', prior to the administering of LA , then take the needle out, then loading the tuohy with LA (here also another concern - inject the LA through the catheter safer than loading the tuohy directly?)

Agree with others that placing an epidural catheter for a 1 hour surgery may be a bit unnecessary, unless pain control was going to be an issue postoperatively. Since you removed the catheter at the end of the surgery, that doesn't seem to be the case. A single shot spinal would be faster (for you and the patient), easier, and result in a more reliable block than an epidural for this case.

True and in respect to solely Spinal procedure and probably what I said "time vs patient status vs failure rate ..."

Many thanks Dr. WholeLottaGame7

 

[DrAmir0078]

For a healthy patient that only smokes with no clear history of GERD. It's probably local culture, but most academic centers in Canada would probably just do a GA with an LMA and titrate some opioids. It doesn't sound like there will be lots of postop pain. In addition, just being a smoker is not an indication for a neuraxial technique either.

True, and I am learning !
Probably, we have seen lots of respiratory complications with smokers, and it looks like we used to it, we prefer neuraxial anesthesia, especially spinal over the GA!
Saying in Canada or even like other advices, LMA for 80 kg+ (Iraqi belly is well known huge, so thinking of GERD is possible or DDX) and LMA is not that protective from stomach secretion, still aspiration is possible, isn't it?

 

[WholeLottaGame7]

Yes, it is true, it was an epidural !

Yes, after I loaded the epidural space with LA, I inserted through the Tuohy needle the spinal needle (very small size) and could go further and felt poking the dura and could get the CSF coming out slowly, then I injected the 1ml of 0.5% Bupivacaine, then after that I withdraw the spinal needle with the trocar out, and kept the tuohy in, then introduced the epidural catheter for about 15 cm, we checked the dropping of NS ... etc

The question is "You prefer to poke the dura with the spinal needle first 'placed inside the tuohy', prior to the administering of LA , then take the needle out, then loading the tuohy with LA (here also another concern - inject the LA through the catheter safer than loading the tuohy directly?)

True and in respect to solely Spinal procedure and probably what I said "time vs patient status vs failure rate ..."

Many thanks Dr. WholeLottaGame7

Thank you for clarifying, I follow you now.

Some people prefer to wait for the spinal to start wearing off before bolusing the epidural, because theoretically adding 15-20ml of fluid to the epidural space will compress the CSF and "push" the spinal higher. The other theoretical concern would be creating a hole in the dura for LA to move from the epidural space to the intrathecal space.

I don't know how true that is, because I never got to see it in action all that often. Anecdotally the few times that we had that scenario, I didn't appreciate a noticeable difference in spinal levels..

 

[DrAmir0078]

Thank you for clarifying, I follow you now.

Some people prefer to wait for the spinal to start wearing off before bolusing the epidural, because theoretically adding 15-20ml of fluid to the epidural space will compress the CSF and "push" the spinal higher. The other theoretical concern would be creating a hole in the dura for LA to move from the epidural space to the intrathecal space.

I don't know how true that is, because I never got to see it in action all that often. Anecdotally the few times that we had that scenario, I didn't appreciate a noticeable difference in spinal levels..

It is my pleasure Dr. WholeLottaGame7

Regarding the hole in the dura was done by Whitacre (Pencan), that small 27 Gauge (I believe) would separate the dura, not cutting it, and by the theories, is it possible for such hole to smuggle LA, these theories need to adapt physics "pressure like of 20 ml in the epidural, patient is supine, , , etc"

So, waiting to wearing off the spinal, do you think 0.5% Bupivacaine (hyperbaric) of only 1 ml will make it possible to achieve the recommended dosage to stop pain for allowing surgical incision - pain free?, for how long? well, what about any possibility that the epidural catheter chance to be dislodged from its position by movement (yet, 4 cm is in the space)

 

[DrAmir0078]

@WholeLottaGame7

P.S.
the time taking after injecting the spinal Bupivacaine 1 ml, to the time of inserting the epidural catheter only (like a minute), and the patient is semi setting position, this one minute probably (just thinking loudly) will make that spinal LA saddle like!
As I know, whenever it is spinal, you have to move the patient supine ASAP, isn't it?

 

[deleted162650]

@WholeLottaGame7

P.S.
the time taking after injecting the spinal Bupivacaine 1 ml, to the time of inserting the epidural catheter only (like a minute), and the patient is semi setting position, this one minute probably (just thinking loudly) will make that spinal LA saddle like!
As I know, whenever it is spinal, you have to move the patient supine ASAP, isn't it?

No. 0.5% bupivicaine is isobaric. Positioning has little to no effect on its spread. What you describe is true if you use 0.75% hyperbaric bupivicaine. Although it takes in excess of 5 minutes of sitting to achieve a true saddle only block.

 

[DrAmir0078]

No. 0.5% bupivicaine is isobaric. Positioning has little to no effect on its spread. What you describe is true if you use 0.75% hyperbaric bupivicaine. Although it takes in excess of 5 minutes of sitting to achieve a true saddle only block.

Hello Dr. SaltyDog,
I hope you are doing well, I am confused but I believe we used both isobaric for epidural, but hyperbaric (heavy) for spinal and both are 0.5% .... The providing company for heavy Marcaine is Aztrazeneca (British - Swedish pharmaceutical company)

That is awesome .... Over 5 minutes (so there is a safe window up to 3 minutes like)

 

[deleted162650]

Hello Dr. SaltyDog,
I hope you are doing well, I am confused but I believe we used both isobaric for epidural, but hyperbaric (heavy) for spinal and both are 0.5% .... The providing company for heavy Marcaine is Aztrazeneca (British - Swedish pharmaceutical company)

That is awesome .... Over 5 minutes (so there is a safe window up to 3 minutes like)

The marcaine in your picture is hyperbaric and will sink. In the states our heavy marcaine is typically 0.75%. Sorry for confusion.

 

[DrAmir0078]

The marcaine in your picture is hyperbaric and will sink. In the states our heavy marcaine is typically 0.75%. Sorry for confusion.

It is alright Dr. SaltyDog,
But still there is a safety window of time to completely sink Marcaine, like I can finish inserting the epidural catheter and taken out..... till I ask the patient to lay supine)

This Marcaine, sometimes we blamed it of malfunctioning (possibly like one of our attending said, it is not because of the medicine, but because orifice of the needle specially the cutting will sit at the edge between dura and epidural, some of the Marcaine will be flushed out)

 

[dhb]

The marcaine in your picture is hyperbaric and will sink. In the states our heavy marcaine is typically 0.75%. Sorry for confusion.

In europe we don't have 0.75% bupi, heavy and iso are both 0.5%

 

[vector2]

Amir, like the others I would recommend doing just a spinal for this type of procedure. If you must do a CSE, do loss of resistance technique to find the epidural space, then use spinal needle through the tuohy and give approximately 2.5-3 cc of 0.5% bupi intrathecally. After the spinal dose is delivered, remove spinal needle and administer 5cc of normal saline through the tuohy into the epidural space and thread your epidural catheter. Having the patient in the sitting position for a minute or two will not result in a saddle block if you are quick with threading your catheter and lying the patient back down.

 

[dhb]

Amir, like the others I would recommend doing just a spinal for this type of procedure. If you must do a CSE, do loss of resistance technique to find the epidural space, then use spinal needle through the tuohy and give approximately 2.5-3 cc of 0.5% bupi intrathecally. After the spinal dose is delivered, remove spinal needle and administer 5cc of normal saline through the tuohy into the epidural space and thread your epidural catheter. Having the patient in the sitting position for a minute or two will not result in a saddle block if you are quick with threading your catheter and lying the patient back down.

Or use an isobaric solution for the spinal.
It is unusual to load the epidural and then do the spinal.

 

[DrAmir0078]

Amir, like the others I would recommend doing just a spinal for this type of procedure. If you must do a CSE, do loss of resistance technique to find the epidural space, then use spinal needle through the tuohy and give approximately 2.5-3 cc of 0.5% bupi intrathecally. After the spinal dose is delivered, remove spinal needle and administer 5cc of normal saline through the tuohy into the epidural space and thread your epidural catheter. Having the patient in the sitting position for a minute or two will not result in a saddle block if you are quick with threading your catheter and lying the patient back down.

Thanks Dr. Vector
Probably what made me inject the Epidural with full dose was because of the difficult position I had holding the tuohy, and it was my Attending advise.
Good to know all your advises.
We have a group on Facebook called Anesthesiologist (For Iraqi Anesthesiologist run by the Chairman of the scientific council of the Iraqi Board of Anesthesia and Critical Care) and I copied and pasted my this post (after here) and it got the attention of a UK Iraqi consultant who had a paper, interesting one on BJA, Dr. Zaher Daoud Shaya, who for the last two days we are discussing the procedure I did.
His paper based on examining S1 response after CSE, in case of iatrogenic injection of LA mix intrathecally.
This is the paper study (published in 2002), you might have your own insight, it is so interesting to be honest!

Evaluation of S1 motor block to determine a safe, reliable test dose for epidural analgesia

 

[DrAmir0078]

Or use an isobaric solution for the spinal.
It is unusual to load the epidural and then do the spinal.

Got it Sir,
Thanks for your insight.
Isobaric for spinal?
What's the point?

 

[caligas]

Got it Sir,
Thanks for your insight.
Isobaric for spinal?
What's the point?

Isobaric has gained popularity in the states due to more stable hemodynamics, longer duration, and some say anecdotally less urinary retention.

 

[DrAmir0078]

Isobaric has gained popularity in the states due to more stable hemodynamics, longer duration, and some say anecdotally less urinary retention.

Bare with me Sir
Isobaric for spinal, for a normal spine curves and patient laid supine, does it have the same effect as hyperbaric, so how about patient head to body angle, do I need to keep the patient without elevating the head up in order to move the isobaric a bit down as we always do for hyperbaric!
Hyperbaric = moves caudaly
Isobaric = stay in the position
Hypobaric = moves cephalad
(correct me Sir please if I am wrong)

 

[deleted162650]

Bare with me Sir
Isobaric for spinal, for a normal spine curves and patient laid supine, does it have the same effect as hyperbaric, so how about patient head to body angle, do I need to keep the patient without elevating the head up in order to move the isobaric a bit down as we always do for hyperbaric!
Hyperbaric = moves caudaly
Isobaric = stay in the position
Hypobaric = moves cephalad
(correct me Sir please if I am wrong)

Well, you’re not entirely right. This explains it better than words ever could:

 

[DrAmir0078]

Well, you’re not entirely right. This explains it better than words ever could:

Holy Love this video Dr. SaltyDog !
I want this glass spine
I am gonna love isobaric, it looks like our - here - counted due to the hyperbaric!
I don't know how to thank you!

 

[DrAmir0078]

@SaltyDog

So if isobaric, is it the same dosages?

As I just read
Hyperbaric vs Isobaric
Hyperbaric = rapid onset block, short duration
Isobaric = slow onset, long duration

But, as potency wise, both caries the same when each hits the ED 50 - ED 95 (am I saying it right?)

 

[deleted162650]

@SaltyDog

So if isobaric, is it the same dosages?

As I just read
Hyperbaric vs Isobaric
Hyperbaric = rapid onset block, short duration
Isobaric = slow onset, long duration

But, as potency wise, both caries the same when each hits the ED 50 - ED 95 (am I saying it right?)

Generally speaking yes, an equal dose of isobaric will take a little longer to set up and last longer than hyperbaric. While I can’t give you a time table, I can tell you that I regularly do 2.5hr total joint replacement cases with 1.5mL isobaric bupivicaine. I have done 5.5-6hr total joint revisions under 3mL isobaric bupivicaine with 20mcg fent.

* our isobaric bupivicaine is 0.5%.

 

[DrAmir0078]

Generally speaking yes, an equal dose of isobaric will take a little longer to set up and last longer than hyperbaric. While I can’t give you a time table, I can tell you that I regularly do 2.5hr total joint replacement cases with 1.5mL isobaric bupivicaine. I have done 5.5-6hr total joint revisions under 3mL isobaric bupivicaine with 20mcg fent.

* our isobaric bupivicaine is 0.5%.

Dr. SaltyDog
if you give 1.5 ml of 0.5% only + / or less than 3 ml + 20 mcg of Fentanyl as a spinal mix and last two and a half hours / six hours respectively !

So I have to tell you some facts here !

I saw an Attending gives 4 ml of 0.5% hyperbaric, claiming the vial has 4 ml!

Mostly others, 2.5 ml of hyperbaric 0.5%

Others 3 ml !

Some mix with 25 mcg Fentanyl if available, others Ketamine 25 mg !


Even for Saddle block with such mentioned concentration, and one of my Friends, his 4th year PGY research was on lowering the dose of Bupivacaine, he concluded that 0.7 ml is enough for Saddle block, 1.4 ml for others !


So, now I know why again we got hemodynamics instability in many patients!

Great!

 

[deleted59964]

Dr. SaltyDog
if you give 1.5 ml of 0.5% only + / or less than 3 ml + 20 mcg of Fentanyl as a spinal mix and last two and a half hours / six hours respectively !

So I have to tell you some facts here !

I saw an Attending gives 4 ml of 0.5% hyperbaric, claiming the vial has 4 ml!

Mostly others, 2.5 ml of hyperbaric 0.5%

Others 3 ml !

Some mix with 25 mcg Fentanyl if available, others Ketamine 25 mg !


Even for Saddle block with such mentioned concentration, and one of my Friends, his 4th year PGY research was on lowering the dose of Bupivacaine, he concluded that 0.7 ml is enough for Saddle block, 1.4 ml for others !


So, now I know why again we got hemodynamics instability in many patients!

Great!

Amir - be careful about using lower doses of spinals based on encouragement here. the rest of us here work in resource rich environments where if our spinal wears off toward the end of a case we have plenty of resource, equipment, and expertise to manage it or convert to GA. A general anaesthetic where you are is a much more risky endeavour.

 

[DrAmir0078]

Amir - be careful about using lower doses of spinals based on encouragement here. the rest of us here work in resource rich environments where if our spinal wears off toward the end of a case we have plenty of resource, equipment, and expertise to manage it or convert to GA. A general anaesthetic where you are is a much more risky endeavour.

Thanks for the wise advice Dr. Jobsfan,
So, without being judgmental, one of the listed causes of using - concluding - high doses, is that because we have limitation in switching to GA with sophisticated monitoring and resources.

But, I really need to make a data of how many times we give spinal even with such doses I mentioned, it ended up either a repetition of the procedure or converting it to GA!

Do you think, it is a good idea, by that time, with collecting of data, we will get a better picture!!

Here, with my posts, you were all understood what working with limited resources, starting from high FGF and to this post of using extra dosages of LA!

Do you think from creativity point of view (thinking out of the box), that an Anesthesiologist who works in our field will have that kind of "out of the box thinking" vs a US or UK or first world Anesthesiologist who exposed in his training to everything available and his mind set will allow him to think out of the box when exposed to suddenly outage of resources?

So, we in the third world, have to write a textbook of Anesthesia titled "Anesthesia in the 4th world", not third, because lots of third world countries have very good and outstanding hospitals!

Thanks for reading me!